Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Wednesday, March 18, 2009

Do We Care?

A reader wrote in the following:

At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home.

Actually, when I initially read the comment, I thought it said the kiddy shrinks don't really "care how bad it is".... as I've re-read it, I realize it's a more accurate portrayal: "the Shrinks don't know how bad it is..." Oh, if it's okay, I'm going to springboard off the "don't care how bad it is"...it's likely quite true that the docs don't know how bad it is.

It is a regular sentiment, however, that people feel their docs "don't care." I'm always perplexed by that because caring is an internal emotion, how do you know if someone cares? You could ask-- hey do you care that I'm miserable? Oh, of course, the answer will be yes. Maybe a doc cares but doesn't quite know what to do, and feels internally squirmy at the inability to fix a patient's suffering. Maybe the patient has a low-key personality style and doesn't adequately convey that they are suffering. One can say they are tormented, but if they say it wedged in between a discussion of NCAA pics while they are knitting, sometimes the tenor of the suffering is attenuated. And one can scream and rant and rave about their suffering, but if they've screamed and ranted and raved about the poor service in a restaurant, well, there's that whole crying sheep issue that makes it hard to filter.

It's not that docs don't care, it's that there is some professional distance. And if the kiddy shrink has lived through the same exact nightmare, he may or may not state this out load. There's an unpredictable element of trade-off in the perception the patient's family might have: 1) I'm so glad you know exactly what I've been through and it's comforting to have this kind of empathy 2) Your experiences color your ability to see clearly all the possible options and you're too caught up in your own kid's issues to fully appreciate my kid's issues, or 3) You've screwed up your kid, why do I want you near my kid? I've used the kid example because our reader provided it, but it could just as easily be a case of pneumonia-- yours got better in 3 days so you can't appreciate that I'm still sick 2 months later.

Some of what comes off as "caring" isn't really about caring at all, it's about the doctor's external display of concern. Some peeps are pretty reserved--they can be distraught, eaten up inside, thinking about a patient's problem, going home and reading about, calling friends for ideas, and still not convey this to the patient-- they can look uncaring and cavalier. Another doc can jump up and down and seem very concerned, but not actually change anything or do anything.

In medical school, I had a brief period where I got eaten up by other people's problems. The summer after my first year, I did a rotation in a psychiatric unit with some more advanced medical students-- it was a very psychoanalytically-oriented staff and we constantly being asked to process what had happened on the units, how we felt about things, and for weeks it seemed we were being asked how we felt about leaving. There was a suicide in the hospital, there was a long-term (meaning years) patient there who was being treated for borderline personality disorder, and she kept lighting fires. The drama was non-stop, the emotions were intense. By the end of the summer, I wasn't sure I should be a psychiatrist, not because I didn't like it, but because I was emotionally over-involved. It got better.

Medicine as a whole, requires some distance. You want your doctor to care enough to hear your pain, to address it, to explore a variety of treatment options, but you don't really need, or perhaps even want, your doctor to feel your pain. And my guess is that our reader is correct that the doctors don't really know how bad it can be.----

Note to Retriever: May I use your entire comment as a free-standing Guest Post?? It was a good synopsis of some of the policy problems behind the mental health system.

24 comments:

I think the reason people become so concerned about if the doctor cares is because there's money involved. If you talk to a friend and they express an interest in your problems you can know it is out of caring, and probably not out of feeling they have to do it.With therapists you can never know if they want to hear about something because they care about what is being said or because they feel that's what they're supposed to do.Personally it's hard for me to trust a person when I worry they're hiding their true feelings.

When my mother was struggling with taking care of my father, who had difficult behavioral issues due to dementia and psychiatric complications of Parkinson's and/or the medications for it, she was very touched by occasional brief but very kind, supportive, and empathetic emails from my father's neurologist.

I'm still struck by his generosity of spirit. To respond to talesofacrazypsychmajor's issue that it's all about the money, this was a VA Neurologist (as a well as a professor and former chair of the neurology department at a major medical school), and I'm sure he wasn't getting paid to write those emails--it is clear that he genuinely cared about his patients and their family members.

When times were tough, my mother would read those emails over and over again.

I understand that doctors need to protect themselves from caring too much, lest it cause them to lose perspective and burn out, but a simply expressed acknowledgement of the difficulties their patients' family members face, some expression of understanding, is an amazing gift.

Even if doctors don't know, they ought to be able to imagine that the lives of family members taking care of behaviorally disordered people is very hard.

A simple acknowledgement of the difficulties, a little bit of reassurance and support for the family member dealing on a day-to-day basis with a loved one whose behavior is very hard to manage, can be a huge help.

Part of it is that we all suffer because of the jerks out there. Anyone who has seen more than, say, three doctors (not just psychiatrists) likely has run into one who really, obviously, and painfully didn't care. So I think that particularly in the first visit or two, a patient is testing the waters ("Please tell me you're not one of...those").

But I think there is also the paradoxical wish that the therapist/shrink can embody the suffering and model an overcoming of it. This is exactly what happens in AA and substance abuse counseling, where therapists often are in recovery. But this seems to work best with an all or nothing issue like substance use, where recovery is unambiguous (after all, you wouldn't want to see a counselor who announced that he had cut down to just a 12-pack per night).

As a purely clinical and not a stigmatizing note, in my experience the most impassioned queries of this kind come from folks with "cluster B" issues, which is not to say that one necessarily implies the other.

By the way, on my blog today I did a rare straightforwardly clinical post (on benzos), would welcome any comments from opinionated parties...

My psychiatrist is extremely empathetic and I NEVER doubt his caring or his empathy with my pain. I don't expect him to dwell on it or suffer angst beyond the time of the session. However, his facial expressions frequently mirror my feelings, a tear may come to his eye, and he usually will say something that expresses his understanding of and sympathy to my pain. It certainly does not LOOK like an act. It looks and feels as if he genuinely cares, genuinely feels my pain, and genuinely understands and has empathy. That REALLY helps me inhabit and feel my often elusive feelings. I would not do with with "professional distance" that entailed a lack of expression of kindness and empathy, Dinah. If my psychiatrist looked uncaring and cavalier I would look for another one. I NEVER feel my psychiatrist's empathy and caring is a result of money, PsychMajor.

I think it is possible for a doctor to be both caring and maintain a distance. This was certainly the case with my primary care doc who was instrumental in helping me through my first depressive episode that required hospitalisation. When I was discharged after five weeks, I wasn’t sure how I was going to get my life back in order. Yes I had ongoing appointments with my psych but there were other health issues I needed to deal with and I wasn’t sure how I was going to manage these and indeed, whether I wanted to.

Then out of the blue, my primary doc rings me just to see how I was doing. As well as appreciating the support, it was the trigger I needed to commit to tackling some of the other health issues.

Now this might be off topic, but I have recently written an op-ed on depression and stigma based on my own personal experience. Part of the reason of this was to show the lived experience of depression, and to show not just doctors, but the population, how bad it can get. The article was published in the weekend edition of our major broadsheet newspaper (our equivalent of the NY Times) and I though the Shrink Rap community might be interested in reading it.

BTW: I am a semi-regular on Shrink Rap but under a pseudonym. I decided not use my pseudonym for this post as I didn’t wasn’t to “out” myself as I prefer the anonymity that a pseudonym offers in posting.

Feel free to use it, tho obviously with the caveat that it was hastily done, and somewhat sloppy!

Re: caring docs. We are blessed these days by having kind and compassionate MDs. But if I had to choose between that and ability to defeat the illness, I'd want the latter!

I think because our family has been thru so much (between the kid and other sick relatives) we are no longer concerned about whether the doctors care so much as that they know what it's really like.

For caring we have each other, and our dog, and our church. We have had doctors who are real !@#holes who have nevertheless done right clinically by family members. Thank God for them. And warm and caring ones who have been clueless. And everything in between.

I think parents of mildly ill kids are more into the social schmoozing skills. What the other parents of severely ill kids want (I think) as much as our family is a doctor who will first assume the best about the parents. Our kids may be terrifyingly out of control and it is easy to judge the inadequacy of some of our management of them. But we are doing the best we can.

The whole refrigerator mom saga taught us that it is easy to see the parents as the cause of difficulties whereas often it is the strain of coping with years and years of illness or a developmental disorder that causes moms especially to develop spaced out, detached or just depressed ways of behaving.

Ironically, in my youth I worked as a chaplain with abused and neglected kids where we looked after such badly treated kids that it was hard not to assume that parents were monsters.

crazy psych major: I don't quite get it, docs get paid and some come off as caring and some don't. Seems to me people want their friends to care, too, and if they don't, it's very upsetting.

Sophia: what a nice doc!

Novalis and others: Here's the rub: part of the issue of 'caring' is in the perception....one person's caring doc is the next person's jerk. If there was a formula: do this and you'll be perceived as caring, we'd all do it. Perhaps you'll say it has to come from the heart, and I'd counter that there are moments when one can have heartfelt caring, and yet the patient perceives it as something else. And what if the doc doesn't actually care...we can say he "should" but what if he doesn't?? Obviously, if he doesn't at all ever, he shoulda been something other than a clinician, but what if it at a particular moment, he just doesn't care--- maybe the patient is distraught about something small and his wife is dying or his kid just smashed the car....maybe he's worried about the last patient who was suicidal...

Retriever: Great point about caring versus delivery of great care: go for the neurosurgeon with the best cure rates, not the best bedside manner.

Do you have a coyote? Is that photo a coyote? I have a coyote-look-alike dog though somewhat different coloration, but she actually was born in the wild, in Egypt, to a feral dog in a feral dog colony.

Anonymous, it's actually not a coyote despite the coloring, and it's not my dog (I often post wolf like pictures of my rescue mutt, tho). The picture is of this really hungry looking wolf I saw at the zoo.

I've read that (once trained) feral dogs are much better pets than the coydogs, wolfdogs here that some people think it cool to adopt. We often wonder if our dog has wolf blood, but hope not as (if so) her behavior will get worse instead of better as she matures.

Look at some of the qualities generaly used to describe a "caring" doctor verses an "uncaring" one - a lot of them have to do with how much a patient believes they've been heard.

Personally - I do not expect a healthcare provider to care about me. What I do expect is that they look me in the eye, they listen to me when I'm talking and do things that outwardly express that they have heard what I am saying - either by answering my questions, or acknowledging my concerns or asking me for more information.

I want an explination about what they think is going on, what their treatment plan is and what outcomes they expect.

I also want real answers to my concerns and not dismissive brush offs.

I dont pay my doctors to be my friends - I pay them to be professionals and I find the doctors who complain about having to be "nice" to patients act more like spoiled children than they do professionals. (note- the above is a general frustration and not a complaint directed to a specific person)

funny you wrote this post, Dinah, because I wrote a very similar one on my blog yesterday evening as well. I happen to think that a lot of people think about (or end up) going into psychiatry because, amongst other things, they have this urge to help people get better, or feel better, or assist them in leading productive, successful lives.

I realise how strong transference/counter-transference forces are, but when a professional realises what qualities their patient has, and what successes could occur if a particular disorder/situation was better managed or dealt with or under control, I personally believe they become much more committed to the experience - problems arise, though, when the client isn't committed, or too committed...

Anon said: "What I do expect is that they look me in the eye, they listen to me when I'm talking and do things that outwardly express that they have heard what I am saying - either by answering my questions, or acknowledging my concerns or asking me for more information."...these are basic social skills that we expect when interacting with most folks, beyond just "Do you want fries with that?" It occured to me that these are some of the same skills addressed by John Robison's book on autism.

It's got me wondering about the neurobiology of caring (remember those 'mirror cells' talked about last year), both as provided and as perceived. There must be evolutionary advantages to being able to demonstrate a sense of caring, as well as to perceive it. But I wonder how it is that people require this bit of 'secret sauce' from their healthcare providers, especially cognitive providers such as shrinks and internists, to maximize the benefit of treatment. I mean, it sounds like a stupid thing to ponder since it seems so obvious; yet, I'd love to understand how it works at a biological level.

Oh, I'm on vacation, too (yes, this is how I relax). Mickey says "Hello, folks."

I am the "anonymous" who described my very empathetic psychiatrist. I talked to him about it today and he said he DOES "take home" the pain of his patients and worries about them and thinks about what he can do to help them. After 42 years of being a shrink that's wonderful.

Years ago my first therapeutic experience was with a psychiatrist recommended through the med school where I then lived. I'd contacted their psychiatry department about anxiety disorder treatments and referrals, and since their own anxiety program was in an interim phase at the time, they suggested several private practice psychiatrists outside the university. The one I chose to work with was in his mid-thirties and about five years into his post residency practice.

Two years later my anxiety disorder hadn't improved much and the underlying dysthymia had intensified because—you guessed it—I didn't feel "cared" for in the therapeutic relationship. During the course of therapy I even ventured to once ask this psychiatrist—tactfully, I hope—how he felt he was showing care. He said by viewing our working relationship as a mutually respectful partnership, by genuinely listening and conveying empathy, by trying to understand who I was in depth and not just superficially, and by being there for me in difficult and painful times; perfect answers. Unfortunately, his behavior didn't reflect this, and at the time I couldn't walk away because the therapeutic frame made it difficult to figure out where my problems ended and his began. I also suspect a couple of the things he said to me would probably rate up there with one of those "Can You Believe" stories; they were definitely sarcastic and contemptuous enough to qualify him as a jerk.

Not long after I terminated treatment with him, he gave up his private practice for a position with the VA as an attending psychiatrist and clinical assistant professor for the med school that had given me his name as a referral. Knowing he now oversees the training of future psychiatrists has always made me queasy, and I sincerely hope his clinical practice and resident supervision primarily deals with meds assessment and management. Fortunately, I did learn some important things about myself once I finally realized how willing I was to take responsibility for his behavior and poor psychotherapy skills and left.

As a post script to all this, out of curiosity I googled his name several years ago and was a bit stunned by what turned up. The professional information was limited, but the personal stuff he'd put out there about himself was enough to confirm what I'd experienced while working with him.

I think Dinah made a good point when she blogged a while back about knowing too much about the personal life of your therapist/shrink. I'm certainly grateful what I learned made it possible for me to depersonalize what happened on a deeper level, but it also made me sad to discover spirituality is important to this man because it makes his lack of empathy and sensitivity that much harder to understand.

I think there is also a certain amount of helplessness in certain situations. For example, I do know that many of my patients have terribly bad lives (I do "know how bad it is"), yet when a single mom with 3 kids has broken her water at 30 weeks (3/4 of the way there, but still dangerously premature), the safe place for her to be is in the hospital (both for her and for her baby).

And I do know that childcare is almost impossible, in fact, I've gone down the road of working wiht social work to try to iron out the childcare thing, that to go there is really just a waste of my time and the social workers.

Yeah, I know it sucks, and I'm sorry it sucks, but if I lost sleep over every thing that sucked, I'd never sleep at all. Which I guess is jsut a much less eloquent way of saying what you said.

Just a few days ago in therapy, I thought I saw his eyes well up with tears; this was after I had finished deeply sobbing, something that, well, touching emotions that deep, even in therapy, is so difficult for me to do, but I want to thank the Anonymous person who replied to my frustrated "So where does that leave me, anyway" rhetorical with the one word answer that I hadn't considered, and I may have blown off at some other time, but was said at the right time, in the right place, on the right night . . . . . I spent several days doing some work on myself, and then went to therapy and discussed how could I forgive myself for stuff, how could I not hate myself, etc. . . . .

Anyway, his empathy is usually really great but this session was notably so. Both before I "let go" . . . and I was glad that I did, that the emotions came out, that that other things that I'm not going to mention here, psychologically, went on along with that, and then afterwards, when I was more able to notice. It surprised me and I was very moved to see the empathy, and the emotion behind the therapeutic demeanor . . . . .

It's hard to explain. He was professional, and yet, his eyes had welled up with tears . . . not fully, but almost. . . . and it wasn't a mask he had on between the emotion and myself, either, though I understood and understand the necessity of . . . . his trying to keep that sort of thing under control, and yet . . . . also not being ashamed for me to see it present, either, being part of the empathy between us . . ., since it was apparent, but he was continuing with therapy in the therapeutic relationship that we have

It's hard to explain, really. If I can really take hold of this idea and continue to process it, and learn to forgive myself . . . . it's not something that happens in one moment, . . . . I do feel different though . . . .

It's just sometimes a person comes completely out of nowhere and says or does that one thing that you need to help you forward and that day last week, it happened to be in the comments on this blog, from one anonymous poster.

A mother on one of the comment sites that I ran into said that 'I cared that her daughter get the right medication for her condition.' That's a nice comment. The meaning of 'caring' might have been different if it had come in the midst of the interview, something like 'We care about her problem with such and such' with the suggestion perhaps that we are having a competition to see 'Who cares the most' or at least that my 'time' in the 'caring race' is about as good as theirs. Sometimes it suggests that the patient is showing a characteristic that might be considered characterological, but 'we have put up with it and our preference is that you do too.'